Download the .PDF Patient Intake Form or Fill out the Form Below.

The information we obtain to complete claims is used to identify you and to determine your eligibility. It is also used to decide if the services and supplies you receive are covered and to insure that proper payment is made.
First Name:*
MI:*
Last Name:*
Phone:*
Gender:*
DOB:*
Height(in.)*
Weight:(lbs.)*
SSN #:*
Primary Address:
Address*
City:*
State:*
Zip:*
Mailing Address: (if different from Primary)
Address:
City:
State:
Zip:*
Guarantor
First Name:
Middle Initial:
Last Name:
Phone:
Gender:
DOB:
Emergency Contact:
First Name:*
MI:*
Last Name*
Relationship:*
Phone:*
Coverage Information:
Primary Coverage:*
Medicare Medicaid Other
Policy Number:*
Group Number:
*if not Medicare or Medicaid, list Company Name, Address, & Phone #*
Secondary Coverage:
Medicare Medicaid Other
Policy Number:
Group Number:
*if not Medicare or Medicaid, list Company Name, Address, & Phone #*
Tertiary Coverage:*
Medicare Medicaid Other
Policy Number:*
Group Number:
*if not Medicare or Medicaid, list Company Name, Address, & Phone #*
Primary Covarage Company Info(If Other is Selected)
Company Name:
Address:
City:
State:
Zip:
Phone:
Secondary Covarage Company Info(If Other is Selected)
Company Name:
Address:
City:
State:
Zip:
Phone:
Tertiary Covarage Company Info(If Other is Selected)
Company Name:
Address:
City:
State:
Zip:
Phone:
Plan of Service:

I accept the Plan of Service agreement.*
Patient's or Authorized Person's Signature:

I accept the Patient's or Authorized Person's Signature.*
Patient's e-Signature:
First Name:*
MI:*
Last Name:*
Authorized Person's Signature(Not patient)
First Name:
MI:
Last Name:
Relationship:
Reason: